Bankole Samuel, MD, Kofi Atiemo, MD, Miller John, Bsc, Czerniach Donald, MD, Cohen Philip, MD, Kelly John, MD, Perugini Richard, MD. University of Massachussetts
Introduction:Laparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed bariatric procedure. Its mechanism of action is debated. One theory held is that the narrow gastric tube retards the flow of nutrients through the stomach; alternatively, some evidence suggests LSG results in augmented gastric emptying. A resolution of this question is important. We present a case report of LSG in a severely obese individual with documented gastroparesis.
Methods:Case report and literature review using pubmed. Search terms included gastroparesis, LSG and gastric emptying.
Results: A 50-year-old severely obese woman 339 lbs and Body mass index (BMI) 51 with idiopathic gastroparesis was referred for LSG. Symptoms included nausea and regurgitation refractory to dietary measures, erythromycin, metoclopramide and botox injection of the pylorus. Preoperatively 0% of a 30cc scrambled egg meal labeled with Tc99 sulfur colloid had left the stomach after 120 minutes. Our standard technique was employed for LSG, and included resection of the greater curvature of the stomach beginning 6 cm proximal to the pylorus with a 40-Fr bougie was used as a sizer. Six weeks postoperatively 50% of an equivalent meal had left the stomach after 90 minutes. She also reported resolution of her symptoms. At 6 months she remained symptom free and weighed 257 pounds (BMI 39)
Paper | Patient Number | Bougie Size (French) | Distance from Pylorus (cm) | Buttress/Over sewing | Study | Meal | Gastric emptying increased |
|---|---|---|---|---|---|---|---|
| Bauman et al | 5 | 32 | 5 or 6 | Not stated | MRI | Water | Yes |
| Michalsky et al | 4 | 36 | 2.5 | None | Tc 99 | Egg | Yes |
| Braghetto et al | 20 | 32 | 2 | Not stated | Tc 99 | Water/Egg | Yes |
| Melissas et al | 9 | 34 | 7 | Oversewing | Tc 99 | Hamburger | Yes |
| Shah et al | 23 | Not stated | Not stated | Not stated | Contrast swallow study | Contrast | Yes |
| Fallatah et al | 15 | 40 | 7 | None | Tc 99 | Egg | Yes |
| Fallatah et al | 11 | 40 | 4 | None | Tc 99 | Egg | No |
| Bernstine et al | 19 | 48 | 6 | Oversewing | Tc 99 | Bread/Water | No |
Discussion: Increased gastric emptying following LSG is evident from our case and is supported by a majority of reported studies. Literature suggests the size of gastric sleeve and the amount of preserved antrum impact the effect on gastric emptying. If increased gastric emptying is indeed the underlying mechanism for weight loss, it may not be necessary to construct increasingly smaller sleeves which have been associated with a greater leak rate. To date studies are small and differ in surgical technique. Large, standardized, randomized studies are needed.
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